Insurance Claim Denied in Colombia: SFC Complaint Guide

Insurance Claim Denied in Colombia: SFC Complaint Guide

Colombia's insurance market is one of the most dynamic in Latin America, and the country has a well-developed regulatory framework for protecting consumers whose insurance claims are wrongly denied. The Superintendencia Financiera de Colombia (SFC) is the central authority for insurance regulation and consumer protection. This guide explains how to use the SFC and other tools to appeal a denied insurance claim in Colombia.

Colombia's Insurance Legal Framework

Insurance contracts in Colombia are primarily governed by the Código de Comercio, specifically the insurance title (Title V, Book 4), which sets out the rights and obligations of policyholders and insurers. The Estatuto del Consumidor Financiero (Law 1328 of 2009) provides additional consumer protection rights, including the right to clear and truthful information, the right to fair treatment, and the right to effective complaint resolution.

The SFC regulates all insurance companies, reinsurers, and intermediaries operating in Colombia. It also operates a consumer complaints function that is directly relevant to policyholders facing unjust claim denials.

Why Insurance Claims Get Denied in Colombia

Alleged non-disclosure (reticencia): Colombian insurance law allows an insurer to avoid a policy if the policyholder failed to disclose a material fact at the time of application. This is called "reticencia" and is one of the most common grounds for denial in life and health insurance. However, Article 1058 of the Código de Comercio limits the insurer's rights in this area: non-disclosure must be material, and the insurer must act within a one-year period from when it first had constructive knowledge of the non-disclosure.

Contractual exclusions: Colombian policies contain detailed exclusion clauses. The SFC and courts have emphasised that exclusions must be brought clearly to the attention of the insured at the time of contracting to be enforceable.

Late notification (mora en la notificación): Policyholders must notify insurers of a claim event within the time specified in the policy. Colombian courts apply a proportionality test — the insurer must demonstrate actual prejudice before relying on late notification to deny a claim.

Motor insurance disputes: Motor insurance (SOAT — Seguro Obligatorio de Accidentes de Tránsito — and voluntary auto insurance) generates a significant volume of disputes. Common denial grounds include driving under the influence, unlicensed driving, and vehicle use outside policy scope.

Disputed medical necessity: Health insurance denials frequently cite lack of medical necessity for procedures or treatments. This is subject to challenge with specialist medical opinions.

The Superintendencia Financiera de Colombia (SFC)

The Superintendencia Financiera de Colombia (SFC) is the regulatory authority for the entire financial sector in Colombia, including banks, pension funds, securities firms, and insurance companies. Its insurance-specific functions include:

• Licensing insurance companies and brokers
• Supervising insurer solvency and product compliance
• Monitoring market conduct
• Receiving and investigating consumer complaints
• Ordering insurers to comply with their contractual obligations and regulatory requirements
• Imposing sanctions for violations of insurance law

The SFC is notable for its relatively strong consumer protection powers compared to some regional peers. Importantly, the SFC can order an insurer to fulfill a contractual obligation to a specific consumer through its administrative powers — this makes the SFC more powerful in individual disputes than many equivalent regulators.

Website: superfinanciera.gov.co

SFC Consumer Complaint Process

The SFC accepts consumer complaints through its Sistema Integrado de Consultas y Solicitudes (SICSS) platform. To file a complaint:

1. Visit superfinanciera.gov.co and access the consumer portal
2. Register and log in to the SICSS platform
3. Select the insurance company and describe your complaint
4. Upload supporting documentation
5. Submit and track your complaint

The SFC aims to process complaints within 15 to 30 business days. The SFC may require the insurer to provide a formal response and may conduct an investigation. Where the SFC finds that the insurer has wrongly denied a valid claim, it can issue a formal instruction to the insurer to pay.

Defensor del Consumidor Financiero: The Internal Ombudsman

Under Colombian financial consumer protection law, all financial institutions — including insurers — are required to designate a Defensor del Consumidor Financiero (financial consumer ombudsman). This is an independent internal officer (or an external ombudsman shared by several institutions) who reviews consumer complaints that have not been resolved through normal customer service channels.

Before escalating to the SFC, policyholders should direct their complaint to the insurer's Defensor del Consumidor Financiero. The Defensor has access to all company files and can review and override customer service decisions. The Defensor must respond within a set timeframe (typically 8 business days) and their findings, while not binding on the consumer, often result in settlement of valid complaints.

You can find the contact details of your insurer's Defensor on the policy documents or on the insurer's website, as required by Colombian regulation.

Step-by-Step: Appealing an Insurance Denial in Colombia

Step 1: Obtain the Denial in Writing

Request a formal written denial (comunicación de rechazo) from your insurer specifying the exact grounds and policy provisions relied upon.

Step 2: Review Your Policy and the Código de Comercio

Check whether the denial ground is genuinely supported by your policy terms and whether the insurer has followed the procedural requirements of Colombian insurance law (especially Articles 1058 and 1053–1080 of the Código de Comercio).

Step 3: File a Formal Internal Complaint with the Defensor

Write a formal appeal to your insurer's Defensor del Consumidor Financiero. Provide all relevant evidence and a clear argument for why the denial is incorrect. This step is important before the SFC will accept your complaint.

Use ClaimBack at claimback.app to generate a professionally structured appeal letter that references the correct Colombian insurance law provisions and presents your case compellingly.

Step 4: Escalate to the SFC

If the Defensor does not resolve the matter satisfactorily, file a complaint with the SFC through SICSS at superfinanciera.gov.co. The SFC's consumer protection powers make this a highly effective escalation channel in Colombia.

Step 5: Consider Legal Action

For complex disputes or large claims, litigation in Colombian civil courts (Juzgados Civiles) or, for collective disputes, through the Superintendencia de Industria y Comercio (SIC) may be appropriate. The Consumer Statute also provides for collective redress mechanisms where systematic insurer misconduct has affected multiple consumers.

Common Mistakes in Colombian Insurance Appeals

Not using the Defensor: Skipping the Defensor del Consumidor Financiero step weakens your SFC complaint and is generally a required first step.

Missing the reticencia defense: If the insurer cites non-disclosure (reticencia), check whether the one-year limitation period for this defense has expired — insurers sometimes assert reticencia after this window has closed.

Failing to gather medical evidence: For health and life insurance disputes, specialist medical opinions and detailed medical records are essential.

Not citing the Estatuto del Consumidor Financiero: This law provides important procedural and substantive rights that strengthen consumer complaints.

Conclusion

Colombian policyholders have meaningful rights and effective institutional support when facing unjust insurance claim denials. The SFC's consumer complaint powers are among the strongest in Latin America, and the mandatory Defensor del Consumidor Financiero system gives policyholders a direct route to independent review. Build a strong case from the outset using ClaimBack at claimback.app and pursue it systematically through the SFC if needed.

Useful Links

• SFC: superfinanciera.gov.co
• SFC Consumer Line: 01 8000 120 100
• SFC SICSS Portal: Accessible through superfinanciera.gov.co